FACTORS AFFECTING UTILIZATION OF EXPANDED PROGRAM ON

IMMUNIZATION AMONG CHILDREN AGED 12-23 MONTHS IN

AGENA TOWN, EZHA WOREDA, GURAGE ZONE, SNNPR, ETHIOPIA,
JUNE 2017G.C

BY: 1. MILISHA NEGESE

2. MISKIR KABTIMER

3. MELAT KETEMA

4. MURSHIDA HUSSAN

5. YOHANNIS DIRIBA

ADVISORS: 1.TEKLEMIKAEL GEBRU (BSC, MPH)

2. MUCHE ARGAW (BSC)

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 WOLKITE UNIVERSITY

COLLEGE OF HEALTH SCIENCE AND MEDICINE

DEPARTMENT OF MIDWIFERY

A RESEARCH PAPER SUBMITTED TO WOLKITE UNIVERSITY,

COLLEGE OF HEALTH SCIENCE AND MEDICINE, DEPARTMENT
OF MIDWIFERY,FOR THE PARTIAL FULLFILMENT OF BACHOLAR
SCIENCES OF DEGREE IN MIDWIFERY

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ACKNOWLEDGEMENT
First, we would like to express our deepest appreciation to our advisor Mr. TEKLEMIKAEL
GEBRU and Mr. MUCHE ARGAW for their dedicated effort, constructive criticism,
encouragement, valuable comments and advices that enabled the production of this research
proposal.

We are also very grateful to express our deepest thanks to Wolkite university and
department of Midwifery for providing us such an opportunity.

Lastly, but not least, our gratitude extends to the families' of the children for their volunteer &
allowance to us on our data collection, and health extension workers for their support and
cooperation during household selection and data collection.

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Table of Contents
ACKNOWLEDGEMENT...........................................................................................................................I
Table of Contents........................................................................................................................................II
ACRONYMS & ABBREVIATIONS.......................................................................................................IV
LIST OF TABLES......................................................................................................................................V
LIST OF FIGURE.....................................................................................................................................VI
ABSTRACT..............................................................................................................................................VII
CHAPTER ONE..........................................................................................................................................1
1. INTRODUCTION....................................................................................................................................1
1.2 BACKGROUND....................................................................................................................................1
1.2 STATEMENT OF THE PROBLEM...................................................................................................2
CHAPTER TWO.........................................................................................................................................4
2.1 LITERATURE REVIEW.....................................................................................................................4
2.2 SIGNIFICANCE OF STUDY...............................................................................................................6
2.3 CONCEPTUAL FRAMEWORK.........................................................................................................8
CHAPTER THREE.....................................................................................................................................9
OBJECTIVES..............................................................................................................................................9
3.1 GENERAL OBJECTIVE......................................................................................................................9
3.2 SPECIFIC OBJECTIVES.....................................................................................................................9
CHAPTER FOUR......................................................................................................................................10
METHODS AND MATERIALS..............................................................................................................10
4.1STUDY AREA.......................................................................................................................................10
4.2. STUDY DESIGN.................................................................................................................................10
4.3 SOURCE POPULATION...................................................................................................................10
4.4 STUDY POPULATION......................................................................................................................11
4.5 SAMPLING UNIT...............................................................................................................................11
4.6 STUDY UNIT.....................................................................................................................................11
4.7 INCLUSION CRITERIA....................................................................................................................11
4.8 EXCLUSION CRITERIA...................................................................................................................11
4.9 SAMPLE SIZE AND SAMPLE TECHNIQUES..............................................................................11
4.10 STUDY VARIABLE..........................................................................................................................13
4.11. DATA COLLECTION AND INSTRUMENTAL TECHNIQUES..............................................14
4.12 DATA QUALITY ASSURANCE.....................................................................................................14
4.13 ETHICAL CONSIDERATION........................................................................................................15
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4.14 DATA PROCESSING....................................................................................................................15
4.15 DATA ANALYSIS.............................................................................................................................15
4.16. DISSEMINATION OF FINDINGS.................................................................................................15
4.17. OPERATIONAL DEFINITION......................................................................................................15
CHAPTER FIVE.......................................................................................................................................17
RESULTS...................................................................................................................................................17
5.1 Socio demographic characteristics of study population...................................................................17
5.2 Family size and child ever born by the mothers...............................................................................18
5.3 Antenatal care (ANC) follow up and TT status of mothers.............................................................19
5.4 Availability and accessibility of vaccination service.........................................................................19
5.5 Maternal behavior and attitude towards child health care and vaccine preventable diseases....20
5.6 Characteristics of the child.................................................................................................................22
5.7 Child sick at the time of appointment day.........................................................................................24
5.8 Reason for defaulting vaccinating a child..........................................................................................24
5.9 Reasons for not vaccinating children.................................................................................................25
5.10 Factors affecting immunization status of children.........................................................................25
5.11.4 Knowledge of age begins, finish and session needed for immunization.....................................28
CHAPTER 6...............................................................................................................................................30
6. DISCUSSION.........................................................................................................................................30
CHAPTER 7...............................................................................................................................................33
7. STRENGTHS AND LIMITATIONS OF THE STUDY....................................................................33
8. CONCLUSIONS AND RECOMMENDATIONS...............................................................................34
REFERENCE.............................................................................................................................................35
QUESTIONNAIRES.................................................................................................................................37

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ACRONYMS & ABBREVIATIONS
ANC Antenatal Care

BCG Bacillus Chalmette Guerin

DHS Demographic and Health survey

DPT Diphtheria, Pertussis, Tetanus

EDHS Ethiopian Demographic and Health survey

EPI Expanded Program on Immunization

HBV Hepatitis B Virus

MCV Measles containing Vaccine

OPV Oral Polio Vaccine

PCV Pneumococcal Conjugate Vaccine

IPV Inactivated polio vaccine

TT Tetanus Toxoid

WHO World Health Organization

WKU Wolkite University

UNICEF United Nation International Children Emergency Fund

E.C Ethiopian Calendar

UNDP United Nation Development Program

HIB Hemophilic Influenza type B

MOH Ministry Of Health

UIP Universal Immunization Program

CI Confidence Interval

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LIST OF TABLES
Table1:- Distribution of the study participants by their socio demographic characteristics in Agena town,
Ezha woreda, Gurage zone, SNNPR of Ethiopia, June 2017 G.C...............................................................17
Table 2:- Distribution of family size in Agena town, Ezha woreda, Gurage zone, SNNPR of Ethiopia,
June 2017 G.C..............................................................................................................................................30
Table 3: - Maternal health care utilization in Agena town, Ezha woreda, Gurage zone, SNNPR June 2017
G.C...............................................................................................................................................................19
Table 4: Vaccination service availability and accessibility in Agena town, Ezha woreda, Gurage zone,
SNNPR June 2017 G.C................................................................................................................................20
Table 5: Respondents knowledge on vaccination and vaccine preventable disease, in Agena town, Gurage
zone, SNNPR ,June 2017 G.C.....................................................................................................................20
Table 6: Respondents knowledge on number of vaccine preventable diseases in Agena town, Gurage
zone, SNNPR, June 2017 G.C…………………………………………………………………………..33

Table7: Respondents knowledge on schedules of vaccination needed for children in Agena town, Gurage
zone, SNNPR of Ethiopia, June 2017G.C...................................................................................................22
Table8: Characteristics of the study children aged between 12-23 months by their place of delivery in in
Agena town, Ezha woreda, Gurage zone, SNNPR, June 2017G.C……………………………………….35

Table 9: What the mothers/caretakers do if child sick at the time of appointment day in Agena town, Ezha
woreda, Gurage zone, SNNPR, June 2017G.C............................................................................................24
Table 10: Distribution of study participants by their response to reason for defaulting of vaccination
in Agena town, Ezha woreda, Gurage zone, SNNPR ,June 2017G.C.........................................................25
Table 11:- Immunization status of children aged between 12-23 moths by socio demographic
characteristics of mothers and children in Agena town, Ezha woreda, Gurage zone, SNNPR, June
2017G.C.......................................................................................................................................................38
Table 12:- Immunization status of children aged between 12-23 months by ANC follow up and TT status
of mothers in Agena town, Ezha woreda, Gurage zone, SNNPR, June 2017G.C.......................................39
Table 13:- Immunization status among children aged 12-23 months by the knowledge of vaccination and
vaccine preventable disease in Agena town, Ezha woreda, Gurage zone, SNNPR, June 2017G.C............28
Table 14:- Immunization status of children aged between 12-23 months by knowledge of age at the child
begins, finishes and session needed to immunization in Agena town, Ezha woreda, Gurage zone, SNNPR,
June 2017G.C...............................................................................................................................................28
Table 15:- Immunization status of children aged between 12-23 months by characteristics of children in
Agena town, Ezha woreda, Gurage zone, SNNPR, June 2017G.C.............................................................29

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LIST OF FIGURE

Figure 1:- Conceptual framework for factors affecting immunization status of the children aged between
12-23 months……………………………………………………………………………………………....19
Figure 2: Coverage of currently given immunization status of children aged between 12-23months in
Agena town, Ezha woreda, Gurage zone, SNNPR, June 2017G.C.............................................................36

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ABSTRACT
INTRODUCTION: - Immunization is a proven tool for controlling and even eradicating
communicable diseases. An immunization campaign carried out by the World Health
Organization (WHO) from 1967 to 1977 eradicated the natural occurrence of smallpox. When
the program began, the disease threatened 60% of the world's population and killed every fourth
victim.

OBJECTIVE : - the aim of this study is to assess immunization coverage and the
factors affecting expanded program of immunization utilization among children in Agena
town, Ezha Woreda, Gurage Zone, SNNP of Ethiopia.

METHODS AND MATERIALS: - community based cross sectional study was carried
out in Agena town; Ezha woreda and a total of 205 children aged between 12-23months from
360 households were included by simple random sampling techniques. Data were collected by
using structured questionnaires through face to face interview. After that the data were edited,
coded and entered into computer and processed by using SPSS Windows version 20 for analysis.
The analyzed data were presented by tables and figures.

RESULTS: - A total of 205 mothers of children aged between 12-23months old were
interviewed with the response rate of 100%. The age of the mother participated in this study was
ranged from 18 to 40 with mean and median of 28.9 ± 3.4 and 28 respectively. From the total of
mothers participated, 76.1% were educated, and 181(88.3%) were married. The most common
ethnic group was Gurage which accounts 178(86.8%) and the majority of the respondents’
religion was Orthodox Christian which accounts 145(70.7%). Majority of Mothers/care givers
occupation were housewife which accounts 94(45.9%). From ten basic recommended
vaccinations, measles were the least taken vaccines 77.56% . About 89% of mothers heard about
vaccination and vaccine preventable diseases and 56% knew correctly the benefit of
immunization. About three fourth (74.6%) of children were fully vaccinated, 17.1% were
partially vaccinated and 8.3% were unvaccinated. The study revealed that children are more
likely to be vaccinated if the child is born at health center (COR=16.3, 95% CI), at hospital
(COR=67.5, 95% CI) than home delivered. Mothers’ who did not followed ANC were less
likely to be vaccinated their children (COR=0.031, 95% CI: 0.009, 0.103) and mothers’ knew the
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VII
correct age at which begins (COR=11.1, 95% CI: 1.45, 85.63) and finishes (COR=70.8, 95% CI:
15.03, 330.3) the immunization.

CONCLUSION AND RECOMMENDATION: -

Immunization coverage among children aged 12-23 months in the town is better than the
national immunization coverage but still below the goal. Majority of mothers heard about
vaccination and vaccine preventable disease and more than half them mentioned correctly the
objective of immunization. Less than half of the mother knows the age at the child begins
immunization. More than four fifth of the respondents knows correctly the age at the child
finishes vaccination. Less than half the respondents know the session needed to be fully
vaccinated. Mothers’ awareness on age at the child begins and finishes immunization, ANC
follow up and institutional delivery services were the significant independent predictors of fully
immunization status of children aged 12-23 months. Children were unvaccinated mostly because
of lack of awareness on proper schedule of immunization followed by fear of side effects and
mothers believe vaccination hurt children. Children were defaulted mostly because of
vaccination time is inconvenient followed by mother usually busy.

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CHAPTER ONE

1. INTRODUCTION

1.2 BACKGROUND
Immunization is a proven tool for controlling and even eradicating communicable diseases or one of the
cost effective public health interventions in preventing and eradicating communicable diseases.
Expanded program on immunization (EPI) is one of the proven achievements in medicine and
public health greatly reducing child and infant morbidity, mortality and health care costs. An
immunization campaign carried out by the World Health Organization (WHO) from 1967 to 1977
eradicated the natural occurrence of smallpox. When the program began, the disease threatened 60% of
the world's population and killed every fourth victim [1].

All countries have national immunization programs, and in most developing countries, children
under five years old are immunized with the standard WHO recommended vaccines that protect
against eight diseases – tuberculosis, diphtheria, tetanus (including neonatal tetanus through
immunization of mothers), pertussis, polio, measles, hepatitis B (HepB), and homophiles
influenza (Hib). These vaccines are preventing more than 2.5 million child deaths each year.
This estimate is based on assumptions of no immunization and current incidence and mortality
rates in unimmunized children [2].

Expanded program of immunization (EPI) in Ethiopia was launched national wide in 1970
with the assistance world health organization, UNICEF and united nation development
program (UNDP). The Objective of program was to progressively increase the
population with access to immunization by 10% annually so that by 1985 at least 50% of
target population would have access to immunization services. However primary health
care review published in 1985 revealed that less than 20% of population had access due
to political instability in the country [2].

Expanded program of immunization is one the fourth programmers along with control of
diarrheal disease, acute respiration disease and notation according to the report 1995 national
review of expanded program on immunization of Ethiopia[3].

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WHO recommended treated disease and also adopted in Ethiopian are measles, pertussis,
Tuber colossi, Tetanus , poliomyelitis and diphtheria. Recently Hepatitis B virus (HBV) and
Hemophilic Influenza (HIB) type B included in EPI in Ethiopian [3].

Ministry of health (MOH) has introduced pneumococcal conjugated vaccine for children
under age of five nationally beginning from 16 October 2011 as part of its nation
immunization[4].

1.2 STATEMENT OF THE PROBLEM

The expanded program of immunization has been initiated to establish programs that can deliver
the primary immunization services to cover 90% of infants worldwide and reduce the public
health burden of the EPI disease [6].

Vaccination has been shown to be one of the most effective public health intervention worldwide
through a number of serious childhood disease have been successfully eradicated. Small pox
eradicated by the immunization campaign carried out by world health organization from 1969 to
1977 [7].

Today about 3.5 million children are dying annually in developing country from three(3)
of the expanded program of immunization target disease ,namely measles, pertussis and
neonatal tetanus. There are about 25,000 children lifelong disability due to poliomyelitis in
developing world [8].

Although estimated global routine vaccination coverage with the first dose of measles
containing vaccine (MCV) reached 82% in 2007, nearly 23.2 million children missed the
vaccine of which 15.03 million (65%) resides in eight countries of Africa, south Asia from
these 1million of them live in Ethiopia(9). According to the 2006 national expanded program
of immunization survey in Ethiopia only 50% of the children of the country were fully
immunized with the variation from one region to another. This shows half of the children were
not fully protected [10].

Immunization is one of the national child survival strategies in Ethiopia to reach

OPT3/measles vaccination coverage of 90% in 2010 which planned to decrease mortality
less than five years of age by 2% [11].

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According to the Ethiopia Demographic and health survey (EDHS) 2016 only 39% of children
12-23 mouths were fully vaccinated and 16% of children didn’t receive any vaccination.
69% of children have received the BCG, 73% the first dose of pentavalent, 81% the first dose of
polio, 67% the first dose of the pneumococcal vaccine, and 64% the first dose of rotavirus
vaccine. Fifty-four percent of children have received a measles vaccination. Coverage rates
decline for subsequent doses, with 53% of children receiving the recommended three doses of
the pentavalent, 56% the three doses of polio, 49% the three doses of the pneumococcal vaccine,
and 56% the two doses of the rotavirus vaccine [12].

In Ethiopia to assess the immunization predictors among children indicated that reason for not
immunized were health workers did not come and give vaccine at the village (28.2%), lack of
awareness about vaccination (25.9%), absence of health facility in the locality (19.1 % ),
vaccination is of no use (7.7%), and vaccination hurts children (5%), also reason for
defaulting are reported absenteeism of vaccinator, lack of awareness on the important of
vaccination (15.2%), and vaccination site is for far away (10.8%) , not knowing whether to
come back for second and third vaccination (9.8%) the main identified [13, 24].

According to the study done in Southern Nation Nationalities and Peoples regional state of
Ethiopia, Hadiya zone, Hosanna town, about 38% of them said age at the child begins
immunization is 45 days after birth and 6.7% said just after birth, 14% at one month, 10.6% at
40 days and 21.6% said they do not know the age at which the child should begin
immunization. Also on the session needed to complete immunization 31.9% answered
three, 25.6% said four, 23.4% responded do not know. On age complete immunization
67.5% responded nine months, followed by 21.1% said they do not know, 4.1% said one
year, 2.1% five year and 5.2% [11].

This study tried to assess the coverage of immunization and factors associated with it
among children residing in selected 08 kebeles of Hosanna town. Immunization coverage was
assessed using the availability of vaccination card and maternal recall. From the total of 508
children aged 12-23months selected and included in this study 480(94.49%) of them were ever
took one or more of the eight recommended vaccine. Based on immunization card and recall,
155(30.51%) children were fully vaccinated, and 28(5.5%) were unvaccinated [11].

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CHAPTER TWO

2.1 LITERATURE REVIEW

Expanded program on immunization (EPI) target disease are leading causes of high childhood
morbidity and mortality as in developing countries .Immunization is there by a timely step for
prevention of mortality and morbidity due to communicable disease in children. The WHO rates
immunization as one of the intervention with a large potential impact on health outcome.
Immunization currently averts an estimated 2-3 million deaths every year. However the
proportion of the world children who receive recommended vaccine has remained steady for past
few years [14].

India has one of the largest Universal Immunization Program (UIP) in the world in terms
of quantities of vaccines used, number of beneficiaries (27 million infants and 30.2 million
pregnant women) covered, geographical spread and manpower involved . India spends more
than Rs. 2000 crores every year in immunization program to immunize children against VPDs
including polio eradication program. Immunizations services are provided through vast health
care infrastructures which primarily include primary health centers and sub-centers [15].

A comparative study conducted in 2006 by kidane T. etal in Bangladesh among children of 12-
23 months of age to access immunization status of children demonstrated that complete coverage
of EPI is associated with educational status of the mother, income and living condition [16].

The study also indicated that children whose mothers were born in rural area /urban and those
mothers were aged less than 30 years are 0.35 and 0.43 times less likely to be fully immunized
respectively [17].

The community based cross sectional survey conducted in 2008 by RUPKP, ETAL INDIA,
Aslam district to assess factors association with immunization coverage of children in
Aslam district indicated as immunization status of the children was significantly higher
distance of the health center was <2km compared with those residing in remote in accessible
areas with a distance of >5km to the health center [18].

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Study conducted in Nigeria (olumuyiwa Do, Ewan et al 2008) on determinants of immunization
status of children in rural areas indicated as mothers of higher knowledge score more fully
immunize children. Also more than half of mothers can correctly calls the symptom s of vaccine
preventable disease and 19% of the mothers felt immunization is good for the child [16].

Study conducted in rural areas Mozambique (jagrativs Etal 2008) on accessing risk factors for
incomplete vaccination and missed opportunity for immunization, revealed that maternal
health utilization like antenatal care, Tetanus Toxoid status of mother, and place of delivery
are those factors that are associated with the immunization status of children this study also
indicated that home delivered children have 2-77 times higher risk of not completing their
vaccination program [21].

A community based cross sectional study conducted in 2007 by IBNOUM,etal in Sudan to assess
factor influencing immunization coverage among children under five years of age revealed
that walking time to the nearest place of vaccination strongly influenced the current
vaccinations status of the children of the mothers who have better assess to vaccine service
(less than 30 minutes walking times to the nearest place of vaccination ) were 3-4 times more
likely has had the correct vaccination than were children or mothers who have to walk 30
minutes or longer [19].

According to EDHS 2011 found that 24% of Ethiopian children have received all recommended vaccine.
This survey report that 15% of children did not receive any recommended vaccine. Vaccination coverage
is more than double in urban areas than in rural areas of the country (48% versus 20%). Birth order has a
close relationship with vaccination coverage. So vaccination coverage generally decreases as birth
order increase, 27% of first born children have been fully immunized, compared with 18% of children
of birth order six and above [20].

According to the Ethiopia Demographic and health survey (EDHS) 2005, the coverage of each
vaccine is low with BCG (60%) DPT1 (58 %) DPT2 (48 %) DPT3 (32 %) OPV0 (17 %)
OPV1 (74 %) OPV2 (65 %) OPV3 (45%) and Measles (35%) and any vaccine is 24 % [25].

According to 2007 and 2008 health and related indicators of Ethiopia, the DPT3, Pentavalent
76% and measles 66% was observed. While the coverage for full immunization of children was
54%. Also in this year in Oromia region the DPT3/ pentavalent / 60.4% was fully vaccinated
[22].
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This case control study conducted in 2008 by (Tadese.H.etal) in southern Ethiopia Wanago Woreda to
assess predictors of defaulting from completing of child immunization identified monthly incomes as
the only factors also cited with defaulting from immunization [23].

A base line survey conducted in 2008 by Bisrat.F and Worku .A, in Ethiopia assess the predictors of
immunization were health workers do not come and give vaccine a the village (28%), lack of
awareness about vaccinations (25.9%), absence of health facility in the locality (19.1%),
vaccination of non-use (7.7%), and vaccination hurts children (5%), Also reason for defaulting
are reported absenteeism of vaccinators, lack of awareness on the importance of vaccination (15.2%)
and vaccinations site is far away (10.9%). No knowing whether to come back for second and third
vaccination (9-8%) are the reason identified [24].

The facility based cross- sectional study conducted by (Samuel G. Teal 2008) at Jimma
university specialized Hospital pediatrics ward to assess missed Opportunity for immunization on 250
children aged between 0- 11 months showed as out of the study participant 36.4% were fully
immunization according to the age schedule [24].

In Ethiopia to assess the immunization predictors among children indicated that reason for not
immunization were health workers did not come and give vaccine at the village (28.2%), lack of
awareness about vaccination (25.9%), absence of health facility in the locality (19.1 % ),
vaccination is of no use (7.7%) and vaccination hurts children (5%), also reason for defaulting are
reported absenteeism of vaccinator, lack of awareness on the important of vaccination (15.2%) and
vaccination site is so far away (10.8%), not knowing whether to come back for second and third
vaccination (9.8%) the main identified [13, 26].

2.2 SIGNIFICANCE OF STUDY

Immunization is by use of vaccine represent remarkable successfully very cost effective means
of controlling and even eradication of infectious disease; improving maternal and child health.

Many effects were made by international organizations and local government makes
immunization coverage. Despite this fact, the existing expanded program on immunization
coverage is very low. Many studies were done to identify the magnitude and factors
influencing the expanded program on immunization coverage simultaneously from
consumers and providers perspective.

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This study will generate information necessary for strengthening expanded program on
immunization and to make possible amendments for programmer and policy makers

So in order to reach the goal of universal immunization planned expansion primary health care
facility and strengthening of management capacity are very important and crucial to delivery
services for those needs. To increase utilization of program, existing problem will be taken to
give appropriate solution.

The finding to this study will help to identifying the magnitude of problem and factors affecting
EPI coverage on study population (area).

The findings of this study are of great significance to immunization program managers
and policy makers in geographical areas with large rural populations. It provides a basis
for rational interventions to improve vaccine delivery in primary healthcare facilities,
improve vaccination coverage indices and reduce the burden of childhood infectious
diseases. The results are of benefit to the county health Management team by providing
actionable information relevant for planning and policy making to improve delivery of childhood
vaccines in the county. This study contributes to the broader literature addressing how to
improve implementation of childhood immunization programs in rural areas by providing an
empirical analysis of challenges faced by program implementers.

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2.3 CONCEPTUAL FRAMEWORK

Figure 1:- Conceptual framework for factors affecting immunization status of the children aged between
12-23 months.

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CHAPTER THREE

OBJECTIVES

3.1 GENERAL OBJECTIVE

 To assess coverage and factors affecting immunization of children aged 12-23
months in Agena town, Ezha woreda, Gurage Zone, SNNP, Ethiopia, May 21-
26/2017.

3.2 SPECIFIC OBJECTIVES

 To determine immunization coverage of 12-23 months of children from May

21-26/2017G.C.
 To find out maternal/caretakers behavior towards vaccine preventable disease
 To identify mothers/caregivers related factors that influence immunization
coverage

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CHAPTER FOUR

METHODS AND MATERIALS

4.1STUDY AREA
• The study was conducted in Agena town, Ezha woreda, Gurage zone, SNNPR of
Ethiopia. Agena is the only town kebele from the 11 kebeles found in Ezha woreda,
Gurage zone, SNNPR of Ethiopia. Agena is located on the road to Butajira and is 192 km
from Addis Ababa (south west), 42 kms from wolkite (east) and 24kms from the
University of Wolkite, found in Gubre. The woreda is bordered in the North with Muhor
Aklil, in the South with Cheha Woreda, in the East with Gumer Woreda and Silte Zone
and in the West with Aboshege. The town has two Kindergartens (KG), two elementary
schools, one high school, one preparatory school and one technical college. Ezha woreda
has 28 health posts, 4 health centres, 4 pharmacies and 5 private clinics. Agena health
centre is one of the health centre found in the woreda which gives service for 11 kebeles.
It has 24 workers as a total, among which 5 of them are PHO, 2 BSc Nurses, 1 BSc
midwife, 9 diploma nurse and 7 of them are other health workers. In the woreda there are
42 health extension workers; 10 of them are working in Agena town.

Climatic condition: - 82% is subtropical, 11% tropical and 7% wet. According to Agena town
municipality office, Agena town has a total population of 5915 peoples. Of these, 2911 (49%)
are females and 3004 (51%) are males. The total numbers of children aged 12-23 months are 620
and household numbers of the town are 718.

4.2. STUDY DESIGN

Community based cross- sectional study design was used to assess factor affecting expanded
program of immunization utilization among children aged 12-23months in Agena town.

4.3 SOURCE POPULATION

All households with children aged 12-23months residing in Agena town.
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4.4 STUDY POPULATION
Randomly selected households.

4.5 SAMPLING UNIT

Children and their mothers/caretakers.

4.6 STUDY UNIT

An individual

4.7 INCLUSION CRITERIA

Households with living children of aged between 12-23 months. In case of two or more children
and twin, one was selected randomly.

4.8 EXCLUSION CRITERIA

If there were more than one child per household and households without children aged between
12-23 months were not included.

4.9 SAMPLE SIZE AND SAMPLE TECHNIQUES

4.9.1 SAMPLE SIZE
The desired sample size was calculated by using population proportion 46.9% (Vaccination
coverage of SNNPR, from EDHS 2016), confidence interval (CI) 95%, and marginal error 5%
and population is normally distributed. Z value is 1.96 as the following.

( z ) 2 ( p ) (1− p)
n= (d ) 2

Where:

n - Sample size

Z - The standard normal variance at 95% CI (1.96)

P - Estimated performance population = 46.9%

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d- Marginal error = 5%

( z ) 2 ( p ) (1− p) ( 1.96 ) 2 ( 0.469 ) (1−0.469)

n= (d ) 2 n= ( 0.05 ) 2

n=383
Since the total population of Agena town is 5915, which is less than 10,000, or 383/5915=0.065
which is >=0.05. Thus, finite population correction formula was used. The final sample size was
n
nf =
calculated as: n where n= initial sample size
1+ ¿
N
¿

nf= final sample size

N= total number of study population

So,

383
f=
383
n 1+
360 ¿
=186
¿

By considering the non-respondents rate of 10%, to calculate sample size:

n f + (n f x10%) = 186+ (186 x 10%) = 205 Respondents

The total 261children were targeted for the study.

4.9.2 SAMPLE TECHINIQUES

Simple random sampling techniques used to select households and to specify the sampling unit.
The total sample size of 205 was allocated proportionally according to the total number of
households who have 12-23months old children in each 10 villages of Agena town. Computer
program was used to ensure the randomness of the sample.

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4.10 STUDY VARIABLE
4.10.1 DEPENDENT VARIABLES
Immunization status of children aged 12-23 months.

4.10.2 INDEPENDENT VARIABLES

Maternal Characters: age, maternal ANC follow up, educational status of mother / caretakers,
family income and attitude of mothers/ care takers are used.

Health Service Issues: average walking distance to reach the nearest health facility , place
of facility, availability and accessibility of health care service.

Characteristics of the child: sex, birth order, place of delivery.

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4.11. DATA COLLECTION AND INSTRUMENTAL TECHNIQUES
4.11.1. DATA COLLECTION INSTRUMENT
The questionnaires were developed in English and then translated into Amharic and translated
back to English for accuracy and consistency. In addition to immunization histories of
children, information on socio-demographic characteristics, economic status, sex of the child,
ANC follow up, place of delivery, maternal immunization, accessibility and availability of
vaccination service, family size and maternal behavior towards immunization were included. In
addition, reasons for defaulting and not immunizing were also added into the questionnaires.

It was asked by data collectors. The data collectors documented the response of the client
correctly. During data collection the code was used to ensure confidentiality of data and then the
collected data were translated back into English.

4.11.2. DATA COLLECTION TECHNIQUES

Data on immunization history was collected in two ways, based on the availability of
immunization card and mothers/caretakers verbal report. After children were identified from the
households, mothers/caretakers of the child were asked for the presence of child’s immunization
card. For the child with immunization card, the information on the doses and types of vaccine
received by the child was copied from the card. If immunization card was unavailable for
the child, the mothers/caretakers were asked for immunization history. The number of
doses the child took and how (the route of vaccine administered) the child took the
vaccine was the way by which immunization history was asked. Information on other
variables was asked directly from the child’s mother/caretaker.

4.12 DATA QUALITY ASSURANCE

Data quality assurance was ensured during data collection, analysis, processing and
documentation. Prepared check list was used .Discussion was done between the data collectors
and supervisor to prevent confusion and miss understanding. The data collectors were
instructed to use the check-list and code during data collection, so that the errors were easily

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identified and corrected before analysis. The check list was checked for completeness by data
collectors, principal investigator and supervisor.

4.13 ETHICAL CONSIDERATION

An official letter which was prepared by Wolkite University, College of Health Sciences and
Medicine, Department of Midwifery and ethics publication committee was submitted to Agena
Health Center and Health Bureau. Verbal informed consent was obtained from the respondents
after explaining the purpose and objective of the study. Participation of all respondents in the
study was on voluntary basis, confidentiality and freedom of each participating respondents were
taken under consideration.

4.14 DATA PROCESSING

After the data were collected, groups were formed to count, cross check and code the data. After
the data were collected, data screening was done by all group members and completeness was
checked before entry into analysis.

4.15 DATA ANALYSIS

The edited and coded data were entered into computer and processed by using SPSS Windows
version 20 for analysis. Data cleaning were executed by using frequencies and cross tabulations
to check accuracy, outliers, consistencies, and missing values. Accordingly, incorrect entries
were identified and re-entered. With the help of this program, descriptive analysis like means,
standard deviations, percentages, etc. … were used to describe the study population in relation to
socio-demographic and other relevant variables. Different tables, charts and graphs were
developed for calculating frequency distribution and percentages and summarized by descriptive
statistics and presented with graphical and written description.

4.16. DISSEMINATION OF FINDINGS

The result of the study is on the way tow be submitted to Wolkite University department of
Midwifery and Ethics Publication Committee office, in Wolkite University health science
library to be used as reference for future researcher and be accessible for utilization by
hard and soft copies to concerned bodies.
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4.17. OPERATIONAL DEFINITION
-Immunization: - a process or procedure that protects the body against an infectious disease.

-Vaccination: - the use of vaccine to prevent specific disease.

-Vaccination schedule: - specified aged and interval for administering vaccines to ensure the
best immunological response.

-Immunization coverage: - proportion of children took vaccination.

-Immunization status: - Being fully or partial vaccinated or unvaccinated

-Fully immunized: - a child aged between 12-23 months old who received one BCG, at least
three dose of pentavalent, PCV and OPV; two doses of Rota virus and one dose of measles [12]

-Partially immunized: - child who misses at least one dose of ten vaccines.

-Unvaccinated: - a child who didn’t receive any dose of the ten vaccines.

Vaccinated- a child who take at least one dose of the ten vaccines

-Knowledge of immunization: - If mothers have awareness about immunization, knows

objectives, age at the child begin, finishes immunization and session to complete immunization
considered as knowledgeable.

Knowledge of vaccine preventable disease: awareness of the disease preventable by

vaccination

-Attitude: - the predisposition to respond for the asked questions (way of thinking or behaving).

-Family size: - average number of families living in one home.

Antenatal care follow up: - attending a care given during pregnancy at health facility

Vaccination defaulter:-child who stopped receiving vaccination before completing

immunization sessions.

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CHAPTER FIVE
RESULTS

5.1 Socio demographic characteristics of study population

A total of 205 mothers of children aged between 12-23months old were interviewed from Agena
town with the response rate of 100%. The age of the mother participated in this study was ranged
from 18 to 40 with mean and median of 28.9 and 28 respectively. From the total of mothers
participated, 76.1% were educated. Majority of the mothers/caregivers that accounts 181(88.3%)
were married. The most common ethnic group in the study area were Gurage which accounts
178(86.8%), followed by Amara 11(5.4%). The majority of the respondents’ religion was
Orthodox Christian which accounts 145(70.7%), followed by Muslim 45(22%) and 7.4% were
followers of other religions such as Protestant, Catholic, and Adventist. Majority of Mothers/care
givers occupation were housewife which accounts 94(45.9%), followed by merchant 49(23.9%).

Table1:- Distribution of the study participants by their socio demographic characteristics in

Agena town, Ezha woreda, Gurage zone, SNNPR of Ethiopia, June 2017 G.C.
Variable Number Percent
Age 15-20years 15 7.3
21-25years 46 22.4
26-30years 94 45.9
31-35years 27 13.2
36 and above 23 11.2
Total 205 100
Mother’s marital status Married 181 88.3
Divorced 13 6.3
Single 6 2.9
Widowed 5 2.4
Total 205 100
Occupational status House wife 94 45.9
Merchant 49 23.9
Gov/ employer 44 21.5
Daily labor 9 4.4
Student 9 4.4
Total 205 100
Ethnicity Gurage 178 86.8
Amhara 11 5.4
Oromo 10 4.9
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 Other 6 2.9
Total 205 100
Religion Orthodox 145 70.7
Muslim 45 22
Protestant 11 5.4
Other 1 0.5
Total 205 100
Educational status Illiterate 49 23.9
Primary 43 21
Junior 35 17.1
Secondary 34 16.6
Preparatory 14 6.8
College/university 30 14.6
Total 205 100
Family monthly income <1000 38 18.5
1000-2000 65 31.7
>2000 102 49.8
Total 205 100

5.2 Family size and child ever born by the mothers

The average family size of the study population was 1.72 ranging from 2 to 8, in which most
families had 4 and more members (76.1%), on average a mother had born 2.7 children and a
maximum of 7.
Table 2:- Distribution of family size in Agena town, Ezha woreda, Gurage zone, SNNPR of
Ethiopia, June 2017 G.C

family size
Frequency Percent

≤3 49 23.9

≥4 156 76.1

Total 205 100.0

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5.3 Antenatal care (ANC) follow up and TT status of mothers
About 91.22% of mothers had followed at least one ANC follow up during their pregnancy of
the child selected for this study and most of them received two or less ANC service. In addition,
89.76% of them ever took one or more doses of TT vaccine, from these only 17.39% were fully
vaccinated.

Table 3: - Maternal health care utilization in Agena town, Ezha woreda, Gurage zone, SNNPR June 2017
G.C

Variables Numbers Percent

1 Antenatal care Yes 187 91.2
No 18 8.8
Total 205 100
2 No. of ANC Two times 19 10.16
taken(n=187) Three times 42 22.5
Four and more 126 67.4

Total 187 100

3.TT immunization Yes 184 89.8
No 21 10.2
Total 205 100
No

4.Number of TT Fully vaccinated 32 17.4

received (n=184) Partially vaccinated 152 82.6
Total 184 100

5.4 Availability and accessibility of vaccination service

The availability and accessibility of vaccination service was assessed by presence of the service and
average walking time to the health facility. All of the respondents (100%) reported that they had
access to the health facility that provides immunization services and majority of them (89.3%)
reported that they were more access to Agena health center followed by Geche private clinic (10.7%)
For majority of the respondents 116(56.6%) the average walking time to the nearest health facilities
was 15 minutes.

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Table4: Vaccination service availability and accessibility in Agena town, Ezha woreda, Gurage zone,
SNNPR June 2017 G.C.

Variable Numbers Percent

Access of health service Yes 205 100
No 0 0
Total 205 100
Average walking distance to the < 15minutes 41 20
nearest health facility 15-30minutes 122 59.5
30-60minutes 42 20.5
Total 205 100

5.5 Maternal behavior and attitude towards child health care and vaccine
preventable diseases
Knowledge of mothers/caretakers on the vaccination and vaccine preventable disease is another
factor assessed in this study, from the total respondents about 182( 88.78%) heard about
vaccination and vaccine preventable disease, of these 76.4% heard from health professionals,
16.5% from school, 3.8% from Television, 2.2% from radio and 1.1% from their friends.
Majority of the respondents (55.6%) mentioned the objective of immunization is to prevent
disease, 29.3% responded it is for child health, 9.8% said they do not know and 5.4% mentioned
it is for other reasons like for diarrheal disease (Table 5).

Table 5: Respondents knowledge on vaccination and vaccine preventable disease, in Agena town, Gurage
zone, SNNPR, June 2017 G.C

Variable Number Percent

Heard about vaccination and vaccine Yes 182 88.78
preventable disease No 23 11.22
Total 205 100
Importance of vaccination To prevent disease 114 55.6
mentioned For child health 60 29.3
For specific disease 11 5.4
I don’t know 20 9.8
Total 205 100
Source of information Health profession 139 76.4

School 30 16.5

Media(TV, Radio) 11 6
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 Friends 2 1.1

Total 182 100

The respondents were also asked the number of vaccine preventable disease they know and
majority of the respondents, 49.26% knew less than or equal to 3 vaccine preventable diseases
and 23.9% of them knew four or more vaccine preventable diseases and 26.83% do not know
any of these diseases. From the ten target vaccine preventable disease, majority of the
respondents (80.8%) knew measles followed by polio (60.2%) and tetanus (30.1%) as vaccine
preventable disease.

Table 6: Respondents knowledge on number of vaccine preventable diseases in Agena town, Gurage
zone, SNNPR, June 2017 G.C
how many vaccine preventable disease do you know
Variables Frequency Percent
3diseases 101 49.26
4-10diseases 49 23.9
I don't know 55 26.8
Total 205 100.0

Respondents’ were asked for their knowledge on age at the child begins immunization, session
needed for completion of immunization and age of completion of immunization. About 46.8% of
them said the age at which child begins immunization is 45 days after birth and 37.6% said just
after birth, 1.5% any time, 0.5% after a year and 13.7% said we do not know the age at which the
child should begin immunization. Also on the session needed to complete immunization 51.71%
answered four, 34.63% said five, and 12.2% responded we do not know. On age to complete
immunization, 83.9.5% responded nine months, followed by 13.66% said we do not know, 2.4%
said at 14weeks.

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Table7: Respondents knowledge on schedules of vaccination needed for children in Agena town, Gurage
zone, SNNPR of Ethiopia, June 2017G.C

Variable Number Percent

Age child begins immunization At birth 77 37.6

At 45 days 96 46.8
Any time 3 1.5
At 1 year 1 0.5
I don’t know 28 13.7
Total 205 100
Age at child complete vaccination At 14weeks 5 2.4
After 9months 172 83.9

I don’t know 28 13.7

Total 205 100
Session needed to complete immunization Three 3 1.5
Four 106 51.7
Five 71 34.6
I don’t know 25 12.2
Total 205 100

These responses were classified into correct or incorrect; according to this survey, 37.6% of
respondents answered correctly for age begin immunization which is just after birth, 83.9% gave
correct answer for the age to complete immunization and only about 34.63% of the respondents
answered correctly for session needed to complete immunization. The majority of the respondents
(78.54%) knew that vaccinations do not make children sick whereas 21.46% respondents said
that it makes child sick.

5.6 Characteristics of the child

A total of 205 children were included in study, majority of them were male which accounts
110(53.7%) while 95(46.3%) were female and majority of the birth orders were 1-3(75.61%),
while 24.39% were 4 and above birth order. Also about 75% women born at health center and
5(2.44%) women delivered at home. From total selected and included children, 188(91.7%) of them
were ever took one or more of the ten recommended vaccines and 17(8.3%) were unvaccinated. All
mothers of vaccinated children showed a vaccination card. Children who completed all ten basic

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vaccinations were 153(74.6%) and 35(17.1%) of them took one or more vaccine but did not finish the
recommended doses (

Table8: Characteristics of the study children aged between 12-23 months by their place of delivery in in
Agena town, Ezha woreda, Gurage zone, SNNPR, June 2017G.C

Variable Frequency Percent

1. Sex Male 110 53.7%
Female 95 46.3%
Home 5 2.4%
2.Place of delivery Health center 154 75.2%
Hospital 46 22.4%
3.Birth order 1-3 155 75.6%
4 and above 50 24.4%
4. Took any vaccination Yes 188 91.7%
No 17 8.3%

5. Vaccination card(n=188) Yes 188 100%

No 0 0
6. Immunization status Fully vaccinated 153 74.6%
Partially vaccinated 35 17.1%
Unvaccinated 17 8.3%

According to our survey, from the children who were took any dose of vaccine, BCG was in
general the most taken one which accounts 90% while OPV0 was the least taken which accounts
23.9%. From the total vaccinated children (188), around 81.46% of children had BCG scar on
their right upper arm while 18.54% of children had no. (Figure 5)

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 90%
87.8% 89.3% 86.8% 87.8% 89.3% 86.8% 87.8% 89.3% 86.8% 87.8% 88.3%
77% 77.56%

23.9%

BCG OPV0 OPV1 OPV2 OPV3 PCV1 PCV2 PCV3 Pent1 Pent2 Pent3 Rota1 Rota2 IPV Measles

Figure 2: Coverage of currently given immunization status of children aged between 12-23months
in Agena town, Ezha woreda, Gurage zone, SNNPR, June 2017G.C

5.7 Child sick at the time of appointment day

Although majority of the respondents that accounts 78.5% took their children to health center for
both vaccination and medical measurement when their children were sick at the time of
appointment day, 15.1% and 6.3% took for medical measurement only and miss until the child
become well respectively.

Table 9: What the mothers/caretakers do if child sick at the time of appointment day in Agena town, Ezha
woreda, Gurage zone, SNNPR, June 2017G.C

Variables Frequency Percent

Took to HC for both vaccination & 161 78.5
medical measurement
Took for medical measurement 31 15.1
only
Miss until child become well 13 6.3
Total 205 100.0

5.8 Reason for defaulting vaccinating a child

According to our survey, 35(17.1%) children were defaulted their vaccination program due to
inconvenient vaccination time (9.76%) and their mothers were usually busy which the second
cause for defaulting reason by contributing 4.9%.

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Table10: Distribution of study participants by their response to reason for defaulting of vaccination
in Agena town, Ezha woreda, Gurage zone, SNNPR ,June 2017G.C

Variables Frequency Percent

vaccination site is far away 1 0.49

vaccination time is inconvenient 20 9.76

Not knowing whether to come back for the second

2 0.98
& third vaccination

Not knowing vaccination time & date 2 0.98

Mother usually busy 10 4.9

5.9 Reasons for not vaccinating children.

The total of 17 respondents who did not vaccinate their children asked for reasons of failure to
vaccinate their children. Majority of them had lack of awareness about proper schedule on
immunization which accounts 9(4.4%) followed by fear of side effects that accounts 6(2.9%) and
vaccination hurt children (0.98%).

5.10 Factors affecting immunization status of children

Different variables are assumed to be associated to immunization status of the children were
included in the study. These include socio demographic characteristics of mothers and child,
maternal health care utilization; child characteristics and knowledge of care takers about
vaccination were included. Factors associated with child immunization and completion of
immunization was seen using logistic regression.
5.11.1 Socio-demographic characteristics of mothers
The association of mothers’ socio demographic characteristics with immunization status of the
children was assessed using bivariate analyses by logistic regression analysis.
Mothers’ educational status was the first factors that shows a significant association by bivariate
analysis, from 23.9% children of illiterate mothers around four fifth of their children were
vaccinated and one fifth are not vaccinated. Also, from 20% of children mothers who attended
primary school, 19% were vaccinated, whereas 0.97% were not vaccinated which is 5 (95% CI:
1.03, 24.29) times more likely to be vaccinated than illiterates. From total of study population,
17.07% of those who educated secondary, in which 16.58% were vaccinated and only 0.48%
were not vaccinated which is 8.72(95% CI: 1.06, 72.24) more likely to vaccinate their children
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than illiterate mothers. Regarding the mother’s occupational status, none of those did show any
significant association with whether the child is vaccinated or not by bivariate analyses. From a
total of 48.8% children of mothers who got an average monthly income ¿1500birr, 47.8% were
vaccinated, whereas 0.97% were not vaccinated which is 8.17(95%CI: 1.82, 36.71) times more
likely to be vaccinated than who got an average of monthly income ≤1500 Ethiopian birr.

Table 11:- Immunization status of children aged between 12-23 moths by socio demographic
characteristics of mothers and children in Agena town, Ezha woreda, Gurage zone, SNNPR, June
2017G.C.

Variables Vaccinated Odd ratio

1.Educational status Yes No Crude odds ratio p-value
Illiterate 39(19%) 10(4.87%) 1
Primary 39(19%) 2(0.97%) 5(1.03,24.29)* 0.046
Junior 33(16.09%) 2(0.97%) 4.23(0.861,20.7) 0.75
Secondary 34(16.58%) 1(0.48%) 8.72(1.062,72.24)* 0.44
Preparatory 13(6.3%) 1(0.48%) 3.33(0.404, 27.467) 0.272
Higher education 30(14.63%) 1(0.48%) 7.69 (0.933,63.449) 0.58
2.Mothers’ Occupational status
Housewife 84(40.97%) 10(4.87%) 1
Merchant 48(23.41%) 3(1.46%) 1.904(0.51,7.17) 0.445
Gov. employee 43(20.97%) 1(0.48%) 5.12(0.63,41.26) 0.306
Daily labor 7(3.4%) 2(0.97%) 0.833(0.151,4.57) 0.197
Student 6(2.9%) 1(0.48%) 0.7(0.078,6.356) 0.69
3.Family monthly income
≤1500 90(43.9%) 1
5(7.31%)
>1500 98(47.8%) 2(0.97%) 8.17(1.817,36.707)* 0.006
5.11.2 Antenatal care (ANC) follow up and TT status of mothers
Maternal health care utilization like ANC follow up and maternal tetanus toxoid status were
another factors assessed in this study if they have an association with child immunization
coverage. Numbers of ANC follow up and doses of tetanus toxoid received also included.
Bivariate analysis shows children of mothers who did not followed antenatal care during their
pregnancy the child selected for these study were 0.031(95% CI: 0.009, 0.103) times less likely
to be immunized than those who do. Children of mothers who had followed ≥ 3 ANC during
their pregnancy were 8.2(95% CI: 1.7, 40.11) times more likely to be immunized than those who
had ≤ 2 follow up. Beside this, children of mothers who had TT immunized were 73.13(95% CI:

19.4, 275.3) times more likely to be vaccinated than those who none TT immunized. And also,
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children of mothers who had received 1-2 doses of tetanus toxoid vaccine were 32.34(95% CI:
9.4, 112.2) and those of received three or above doses were 34.1(95% CI: 3.9, 299) times more
likely to be vaccinated than whose mother did not received. (Table 12)

Table 12:- Immunization status of children aged between 12-23 months by ANC follow up and TT status
of mothers in Agena town, Ezha woreda, Gurage zone, SNNPR, June 2017G.C.

Variables Vaccinated Odds ratio p-value

1. ANC visit Yes 180(87.8%) 7(3.4%) 1
No 8(3.9%) 10(4.87%) 0.031(0.009,0.103)* 0.0001
2. Number of visits(n=187) ≤2 15(7.3%) 3(1.46%) 1

≥3 165(80.48%) 4(1.95%) 8.2(1.7, 40.11)* 0.009

3. TT immunized Yes 180(87.8%) 4(1.95%) 73.13(19.4,275.3)* 0.0001
No 8(3.9%) 13(6.34%) 1
4. TT status of mother None 10(4.88%) 11(5.37%) 1
1- 147(71.71%) 5(2.44%) 32.34(9.4,112.2)* 0.002
2doses
≥3doses 31(15.12%) 1(0.49%) 34.1(3.9,299)* 0.001

*significant at 95% CI

5.12.3 Mothers’ knowledge on vaccination and vaccine preventable diseases

In this study association of mothers’ knowledge on vaccination and vaccine preventable disease
with child immunization status was also assessed by bivariate analysis. The result from bivariate
analysis shows that, mothers who did not heard about vaccination and vaccine preventable
disease and who says the objective of vaccination we don’t know were less likely to vaccinate
their children which is 0.011(95% CI: 0.003, 0.04) and 0.0034(95% CI: 0.0004, 0.03) times less
likely to vaccinate their children than who heard and said to prevent disease respectively. In
contrast to this, mothers’ knowledge of objective of immunization who said for child health and
for specific disease did not show statistically significant association with the child immunization
status (Table 12).

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Table 13:- Immunization status among children aged 12-23 months by the knowledge of vaccination and vaccine
preventable disease in Agena town, Ezha woreda, Gurage zone, SNNPR, June 2017G.C.

Variables Vaccinated Odds ratio(95% CI) p-value

Yes No
1. Do you heard about Yes 179(87.3%) 3(1.46%) 1
vaccination and vaccine No 9(4.4%) 14(6.83%) 0.011(.003,0.044)* 0.0001
preventable disease
To prevent 114(55.6%) 1(0.48%) 1
disease
2. Objective of For child 58(28.3%) 2(0.97%) 0.25(0.022,2.8) NI 0.268
immunization mentioned health
For specific 11(5.4%) 1(0.48%) 0.096(0.0056,1.65) NI 0.107
disease
I don’t know 5(2.4%) 13(6.34%) 0.0034(0.0004,0.031)* 0.0001
NI-not included * significant at 95% CI

5.11.4 Knowledge of age begins, finish and session needed for immunization

In this study association of mothers’ correct knowledge on immunization schedule and child
vaccination was assessed by bivariate analysis, shows that children whose mothers know the
correct age at the child begin and finish immunization was more likely to be vaccinated than who
did not. Children of mothers who know correct age at begin immunization were 11.1(95% CI:
1.45, 85.6) times more likely to be vaccinated than who did know and those of who know the
correct age of finishing immunization were also 70.8(95% CI: 15.03, 330.3) times more likely to
be vaccinated. Regarding to session needed for immunization, shows that mother who know correct
sessions needed for the immunization were 9.71(1.26,74.59)(95% CI: 1.26, 74.6) times more likely
to complete child immunization than who did not know. (Table 13)

Table 14:- Immunization status of children aged between 12-23 months by knowledge of age at the child
begins, finishes and session needed to immunization in Agena town, Ezha woreda, Gurage zone, SNNPR,
June 2017G.C.

Variables Vaccinated Odds ratio(95% CI) p-value

Yes No
1. Know correct age of begin Yes 77(37.6%) 1(0.48%) 11.1(1.45,85.63)* 0.006
immunization
No 111(54.14%) 16(7.8%) 1

2.Know correct session needed Yes 71(34.63%) 1(0.48%) 9.71(1.26,74.59)* 0.0081

to complete immunization
No 117(57.1%) 16(7.8%) 1
3. Know correct age of Yes 170(82.9%) 2(0.97%) 70.8(15.03, 330.3)* 0.0001
complete immunization
No 18(8.78%) 15(7.3%) 1

5.11.5 Child characteristics

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The associations of child characteristics like sex and place of delivery with the immunization status
of child were assessed by bivariate analyses. About 49.3% of male and 40.44% female children were
vaccinated. As the analysis shows that male and female children born at health center were 16.3
(95% CI: 2.48, 106.7) times more likely to be vaccinated and children born at hospital were 67.5
(95% CI: 4.7, 972.6) times more likely to be vaccinated than children born at home. But sex of the
child did not have statistically significant association with the child immunization status. (Table 14)

Table 15:- Immunization status of children aged between 12-23 months by characteristics of children in
Agena town, Ezha woreda, Gurage zone, SNNPR, June 2017G.C.

Variables Vaccinated Odds ratio (95% CI) p-value

1. Sex of child Yes No
Male 101(49.3%) 9(4.4%) 1.032(0.358,2.62) NI 0.717
Female 87(40.44%) 8(3.9%) 1
2. Place of delivery
Home 2(0.97%) 3(1.46%) 1
Health center 141(68.8%) 13(6.34%) 16.3(2.48,106.7)* 0.01
Hospital 45(21.9%) 1(0.48%) 67.5(4.66,972.63)* 0.001

*significant at 95% CI NI-not included

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CHAPTER 6

6. DISCUSSION
This study tried to assess the coverage of immunization and factors associated with it among
children aged between 12-23 months old residing in selected households of Agena town, Ezha
woreda, Gurage zone, SNNPR of Ethiopia.
Immunization coverage was assessed using the availability of vaccination card and maternal
recall. Based on this, 74.6% of children were fully vaccinated, 17.1% were partially vaccinated
and 8.3% were unvaccinated. From the basic recommended vaccinations, BCG was the highest
taken vaccine and measles was the least taken vaccines, 90% and 77.56% respectively. In the
study area, BCG is given at birth and at next visit for child who did not got at birth, this the
reason for why scored high percent. The OPV vaccine coverage was slightly less than the
coverage of the pentavalent vaccine as it is not given routinely by Agena health center for
newborn that indicates the lowest coverage of OPV0 which is 23.9% although given each other
according to the EPI schedule. Also the measles coverage is lower than the PCV3 (86.8%)
coverage because of drop out and the time gap between the two vaccines, in which the mother
forgot the measles vaccine.

When we compare the immunization coverage of Agena town with EDHS 2016:
The percent of fully vaccinated is about twofold greater, or higher by 35.6%, even though our
sample size and study area is smaller than national level; but the percentage of unvaccinated
children is somewhat similar. Both BCG and first dose of the pneumococcal vaccine coverage in
our survey is higher by 21%, first dose of pentavalent higher by 15%, the first dose of rotavirus
vaccine is higher by 24% and the first dose of polio is also higher by 7%. According to our
survey 77.6% children have received measles which is higher by 23.6%. With 87% of children
receiving the recommended three doses of the pentavalent which is higher by 34%, 87% the
three doses of polio which higher by 31%, 87% the three doses of the pneumococcal vaccine
which higher by38%%, and 88% the two doses of the rotavirus vaccine which higher by 32%
[12]. From the total coverage of vaccination, most of the children took BCG and vaccinations
given on 10weeks which is 90% and 89.27% respectively.

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And also when we compare with the coverage of immunization status of Hosanna town, the
percentage of fully vaccinated is higher by about 44%, even though the proportion of
unvaccinated children is higher by 2.8% than that of Hosanna [11].

Mothers/immediate care takers knowledge on vaccination and vaccine preventable disease was
also assessed in this study. About 89% of mothers/immediate care takers heard about vaccine
and vaccine preventable disease, from these only 55.6% of them mentioned that vaccination is
important to prevent disease. Regards to knowledge of mother about at which age child begins,
finish and the session needed to complete immunization, 37.6% of the respondents knew the
correct age at the child begins immunization, 83.9% when to complete immunization and 34.6%
knew session needed. The objective of immunization mentioned in this finding is less by 23.9%
when compared with the survey done in Ambo woreda by Belachew Etena, 2012 [17].

Different reasons were given by the respondents for reasons of failure to immunize and
defaulting. Majority of them had mentioned vaccination time is inconvenient(9.76%), mother
usually busy4.9%, lack of awareness on proper schedule of immunization 4.4% fear of side
effects 2.9% while did not knowing whether to come back for the second and third vaccination is
equivalent with vaccination hurt children that accounts 0.98%. This finding is higher with study
conducted in Ethiopia (care group polio project base line survey in Ethiopia) [23].

This study also tried to assess factors affecting the immunization status of the children by
classifying the status of the children into two categories vaccinated or not and whether the child
is fully vaccinated. Factors affecting these two variables were analyzed separately and factors
related to them were identified by bivariate analysis using binary logistic regression.
Based on the bivariate analysis educational status and family monthly income showed significant
association with the immunization status of the children. Mothers who attended primary school
were more likely to vaccinate their children and those who attend high school were more likely
to vaccinate their children than those of illiterate. This is consistence with the study done in
Burkina Faso [27]. But mothers attended junior and higher education and mothers’ occupational
status had no association with child immunization status.

Place of delivery is another child characteristic which showed a significant association with the
immunization status of children aged between 12-23 months by bivariate analysis. Health center
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born children were 16.3 times more likely to be vaccinated and children born at hospital were
67.5 times more likely to be vaccinated than who born at home. This similar with study done at
Mozambique in which home delivered are 2.27 times risk of incomplete immunization [20].
These indicate that, mothers who delivered at health institution are more aware about the benefit
of vaccination than mother who delivered at home. The explanation related to this may be
mothers who give birth at health institution are more near to the health service and when they
giving birth at health institution, most of the time the first doses of vaccination are given after
birth at health institution.

ANC follow up and TT status of mothers is maternal health care utilization were variables
included in the bivariate analysis. ANC follow up was showed having significant association
with child immunization status. Children of mother who followed ANC were 32 times more
likely to be vaccinated than those with no follow up, which is consistence with the study done in
India [18].

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CHAPTER 7

7. STRENGTHS AND LIMITATIONS OF THE STUDY

7.1. Strengths
By selecting children aged between 12-23 months, which measures the recent immunization
program performance and those complete the immunization, may reduce the recall bias and
provides information concerning the situation at a given time. The mothers/caretakers of
children who have the correct information on the child’s immunization history were interviewed
and factor affecting immunization status of their children was assessed. Use of logistic
regression for analysis of data to control for possible confounders were used.

7.2. Limitations
Immunization coverage by report of mother may under/over report the immunization coverage
because mothers may not remember doses that child took due to recall bias. This study did not
consider validity of the doses of vaccines child takes andattitude of the mothers/caretakers was
not studied, which may have an impact on immunization. The sampling process is susceptible to
selection bias, andqualitative method was not included to answer why question by the
respondents. Being cross sectional study design does not show the temporal relationship of
cause effect relationship and not good for studying rare diseases or diseases with short duration
and also not ideal for studying rare exposures.

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CHAPTER 8

8. CONCLUSIONS AND RECOMMENDATIONS

8.1 CONCLUSIONS
 Immunization coverage among children aged 12-23 months in the town is better than
the national immunization coverage but still below the goal.
 Majority of mothers heard about vaccination and vaccine preventable disease. More than
half them mentioned correctly the objective of immunization
 Less than half of the mother knows the age at the child begins immunization
 More than four fifth of the respondents knows correctly the age at the child finishes
vaccination
 Less than half the respondents know the session needed to be fully vaccinated
 Mothers’ awareness on age at the child begins and finishes immunization, ANC follow
up and institutional delivery services were the significant independent predictors of fully
immunization status of children aged 12-23 months.
 Children were unvaccinated mostly because of lack of awareness on proper schedule of
immunization followed by fear of side effects and mothers believe vaccination hurt children
 Children were defaulted mostly because of vaccination time is inconvenient followed by
mother usually busy
8.2 Recommendations
Based on the finding of the study the following recommendation are forwarded
The Agena town and Woreda health office is better if work to raise the awareness by designing
proper health education targeting the mothers/caretakers on benefit, correct age the child should
begin and finishes as well as session needed for complete immunization
The health office and health workers of the town had better increase the ANC follow up and
institutional delivery which is also used to increasing the immunization coverage
Appropriate vaccination time should be arranged for the mothers/caretakers, like farmers and
daily laborer, who do not have enough time during the working day after assessing the need.
Proper information on the doses and timing of the vaccination should be given for the mother
coming for immunizing their child by health profession working on immunization service
Vaccines should be available all time in the health institution giving vaccination service with
appropriate storage materials

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REFERENCE
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2010 September 13]; Available from: http://www.who.int/mediacentre/factsheets/fs288/en/index.html

2:World health report 2001, birding the gap of world health organization. Geneva PP. 5014. 3:
WHO united nation foundation 2009, immunization in practice module of health staff 2009 up date,
united printers, Ethiopia?

4. Aaby P, Ben CS, (2009) Assessment of childhood immunizations coverage. Lancet 373(9673): 1428.

4. Schucha A, Kroger A (2011) General Recommendations on Immunization. US Department of Health

and Human Services,

5:Disease control priorities project estimate of current burden of vaccine preventable Disease and
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6: Zeleke SA, 2005. Difficulties with vaccine program. The lancet; PP 21

7: Angela Gentile. Pediatric disease burden and vaccination recommendation understanding local;
differences. International Journal of infectious disease (review), 2010 ;( 30): 1019- 29.

8: Samuel Girmaetal 2000. Missed opportunity for immunization in Jimma Hospital Ethiopia Journal of
health science 10(2): 110- 109.

9: WHO Global elimination of measles. Geneva: world health organization 2009 16 April, 2009.

10:Kidane T,Tigzaw A, Sahile Mariam Y, Bul to T, mengistu H, Belay T, etal .2006 National EPI
coverage survey report, Ethiopia Journal of health development 2008; 22(2): 148-57.

11: Bizuneh Ayano, Factors affecting immunization status of children aged 12-23months in Hosanna
town, Hadiya zone, Southern nation nationalities and people’s regional state of Ethiopia, July 27, 2015.

12. Central Statistical Agency (CSA) [Ethiopia] and ICF Macro. 2016. Ethiopia Demographic
and Health Survey 2016. Addis Ababa, Ethiopia, and Calverton, Maryland, USA: p.26, October
2016
13: Biryani Y, Universal childhood immunization: a realistic yet not achieved goal Ethiopia journal of
health development. 2008: 22(2); 146-7.

14: Elzein HA etal. Rehabilitation of EPI in Sudan following poliomyelitis outbreak. Bulletein of the
world health Organization; 2008; 76 (4): 33541.

15: Olumuyiwaoo, Ewan FA, Francols PM Vincet IA. Determinants of vaccination coverage in rural
Algeria. BMC public health 2008; 8 (381): 2458 – 8.

16:Worku Animaw,Wondimagegn Taye,Behailu Merdekios,Marilign Tilahun and Gistane

Ayele;Expanded program of Immunization coverage and associated factor among children age 12-23

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month in Arba Minch and Zuria District, Southern Ethiopia,2013.http:/www.biomedcentral.com/1471-
2458/14/464

17: Belachew Etana; Factor Affecting Immunization Status of Children Aged 12-23 Months in Ambo
Werada, West Shewa Zone Oromia Regional State, Ethiopia, May 2012

18:RUP KP , Manash PB, Jagadish M. Factors associated with immunization coverage of children in
Assam , India over the first year of life. Journal of topical pediatrics 2008; 52 (4):249-52.

19:IB nouf A, Vanden Borne H, Maarse J, factors affecting immunization coverage among children
under five years in Khartomstate, Sudan SA fampract 2007; 49 (8): 140- f.

20:Jagarti VJ, Caroline DS, Ilesha VJ, Gunnar Brisk factors for incomplete vaccination and missed
opportunity for immunization in rural Mozambique, BMC Public health 2008 :(98). (161).

21:FOMH health and health related indicators in : department planning and program. Editors Addis
Ababa 2008.

22:Tadesse H, Deribew A, Woldie M. Predictors of defaulting from completion of child

immunization south Ethiopia, may 2008- A case control study . BMC public health 2009: 9n (150).

23:Bisrat F. Worku A. care group polio project base line surveys I Ethiopia 2008.

24: Samuel Girmaetal 2000. Missed Opportunity for immunization in Jimma Hospital. Ethiopia Journal
of health science 10 (2): 100 – 109.

25: General statistics Agency. Ethiopia demographic and health survey 2005; pp. 129.

26: FMOH. Health and health related indicators in: department planning and program, editor. Addis
Ababa 2008.

27. Aboubakary S, Seraphin S, Kouyaté B, Marylène D, Janice G, Gilles B. Assessment of

factors associated with complete immunization coverage in children aged 12-23 months: a cross-
sectional study in Nouna district, Burkina Faso. BMC International Health and Human
Rights2009; 9(suply 1):1-15.
28. Parthia D, B. N. B. Determinants of Child Immunization in Fourless-Developed States of North
India. Journal of child health care 2002; 6(34):34-50.

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QUESTIONNAIRES
WOLKITE UNIVERSITY

COLLEGE OF HEALTH SCIENCE AND MEDICINE

DEPARTMENT OF MIDWIFERY

Questionnaires will be developed to assess factor affecting expanded program of immunization utilization
among children in Agena town, May 2017.

INTRODUCTION

Dear participants,

MY Name is _______________. I am working as data collectors for the research conducted on EPI by 4 th BSc
Midwife student of Wolkite University. I am here today to collect information on factors affecting EPI
implementation among children in Agena town. This study information necessary to strengthening expanded
program on immunization and to make possible amendment for programmers and policy makers. Therefore,
your participation and genuine responses are important for the achievement of study objective which is not
obligatory it is based on your willingness.

Are you volunteer to participate?

1. Yes
2. No

PART I – SOCIO DEMOGRAPHIC CHARACTERISTICS OF RESPONDENTS

1.1 Mother’s age

1.2 Mother’s marital status 1. Single 2. Married

3. Widowed 4. Divorced

1.3 Mothers Educational status 1. Illiterate 4. Grade 9-10

2. Grade 1-4 5. Grade 11-12

3. Grade 5-8 6. Higher education

1.4 Occupational status of mothers 1. House wife 4. Daily labor

2. Merchant 5. Student

3. Government employee 6. Other

1.5 Family monthly income

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 1.6 What is your ethnicity? 1. Gurage 3. Amhara

2. Oro mo. 4. Other

1.7 What is your religion? 1. Orthodox 3. Protestant

2. Muslim 4. Catholic
5. Other

PART II- INFORMATION RELATED CHILDREN

2.1 Child birth date:- _____ day ____month ____ year (in Current age in months:
month)

2.2 Sex of child: 1. Male 2. Female

2.3 Number of children’s order sibling

2.4 Family size

2.5 Place of delivery? 1. At home 2. Health center 3. Hospital

2.6 If delivered at home, who attended the delivery? 1. Relatives 3. Health personnel

2. Neighbors 4. TBA(untrained)

5. TTBA(trained)

PART III-INFORMATION RELATED TO MATERNAL AND CHILD HEALTH CARE UTILIZATION

3.1 Have you attended ante natal care during pregnancy? 1. Yes 2. No

3.2 If yes, how many times did you attend? 1. Two times 2. Three times 3. Four and more

3.3 Have you received tetanus vaccination during pregnancy? 1. Yes 2. No

3.4 If yes, 1. Fully vaccinated 2. Partially vaccinated

3.5 Is there facility which vaccination service near to you? 1. Yes 2.No

3.6 If yes, which health facility is near to you? 1. Health center 2. Hospital 3. Private clinic

3.7 How much does it take to you to reach nearest healthy facility in Kilo meter (km) _____?

1. < 15 minutes 2. 15’-30min

3. 30’-1hr 4. >1hr

3.8 Do you heard about vaccination and vaccine preventable disease? 1. Yes 2. No

3.9 If yes, from where you heard? 1. Television 2. Radio 3. From school

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 4. Health worker 5. From friend 6. Others_______________________

3.10 Could you mention the importance of vaccinating a child? 1. To prevent disease 2. For child Health

3. For specific Disease 4. Don’t know

3.11 How many vaccine preventable disease do you know? 1. 3diseases 2. 4-5diseases 3. 6-10diseases

3.12 If yes, which of the following do you know? 1. Measles 2. Polio 3. Tetanus
4. Diphtheria 5. Hepatitis virus 6. Pertussis

7. Haemophilus influenza 8. Tuberculosis 9. Pneumonia

3.13 How many Vaccination session are needed for a child to be fully protected ?

1. Two 3. four

2. Three 4. Five 5. I Don’t know

3.14 Do you tell me the age at which the child begins immunization ? 1. At birth 2. one month after
birth

3. Any time 4. After a year 5. I don’t

know

3.15 At what age the child should complete immunization? 1. At 6weeks 2. At 10weeks

3. At 14weeks 4. At the end of 9months

3.16 Do you think vaccination will make your child sick? 1. Yes 2. No

3.17 Does your child take any vaccination? 1. Yes 2. No

3.18 If yes (Q 3.17), does it she/ he protected from disease? 1. Yes 2. No

3.19 If no (Q 3.17), what are reasons for not receiving any vaccine?

1. Absence of health facility in the locality 4. Lack of awareness about it

2. Vaccination of no use 5. Fear of side effect

3. Vaccination hurt children 6. Others_____________

3.20 Do you have a card where vaccinations are written down? 1. Yes 2. No

3.21 If yes, Copy the immunization data from the card.

Vaccine 1. At 2. At 3. At 4. At 5. At 6.Unvaccinated
taken birth 45days 10weeks 14weeks 9months

BCG

OPV0

OPV1

OPV2

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 OPV3

PCV1

PCV2

PCV3

Pentavalent1

Pentavalent2

Pentavalent3

Rota1

Rota2

Measles

3.22 Has a child had any vaccinations that are not recorded on this card, including vaccinations given in a national immunization
day campaign? 1. Yes 2. No

3.23 If no, did a child ever have any vaccinations to prevent him/her from getting diseases, including vaccinations received in a
national immunization day campaign? 1. Yes 2. No 3. don’t know

3.24 Would you tell me on which vaccinations session your child is? 1. First vaccination 2. 2 nd
vaccination

3. 3rd vaccination 4. 4th vaccination 5. 5th vaccination

3.25 Does the child have a BCG scar on his/her upper left arm? (Observe) 1. Yes 2. No

3.26 What are the reasons for defaulting? If child is defaulter

1. Vaccination site is far away 2. Vaccination time is in convenient 3. Absenteeism of vaccinators

4. Not knowing whether to come back for second and third vaccination 5. Not knowing vaccination time and date.

THANK YOU

Name of the data collector____________________ Signature________ Date___________

Supervisor ______________ signature _________________ date _______

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